Recent improvements in measures of patient safety in nursing homes look, at first glance, like a monumental policy success. The reported percent of nursing home residents suffering pressure sores, falls, and urinary tract infections decreased dramatically since the early 2000s, when policymakers began numerous initiatives focused on improving nursing home quality. However, skepticism has emerged as to whether the improved performance on patient safety measures truly reflects improvements in residents? outcomes or, alternatively, simply reflects changes in documentation since the data for the patient safety measures are self-reported by nursing homes. Policymakers interested in improving outcomes and maximizing the usefulness of the patient safety measures share this skepticism, especially in cases where performance on patient safety measures is not matched by performance on other established measures of quality. Several recent New York Times articles drew national attention to the issue, highlighting several cases where consumers felt misled by high quality ratings into choosing nursing homes that fell far short of expectations. Whether reported improvements in patient safety reflect true improvements in nursing home resident outcomes has particular import for disparities in the quality of nursing home care. It is well known that nursing homes with a high proportion of Medicaid residents, often located in poor neighborhoods and disproportionately serving members of racial and ethnic minority groups, provide lower quality of care on average. Although high- Medicaid nursing homes had notable improvements in many patient safety measures over the past two decades, if this performance does not reflect resident well-being and outcomes, these scores may mask the need for real quality improvement and do little to address disparities in nursing home care. Our overall objective in this mixed-methods study is to assess whether and how nursing homes are improving patient safety, providing both quantitative and qualitative evidence as to how high-performing and high- improving nursing homes achieve these scores. By correlating this performance with other well-established measures of quality and potential mechanisms for improvement, we will gain insight as to whether these improvements are meaningful and whether they are equitably distributed. To address the first three Aims, we propose econometric analysis of multiple merged data sets for 2011-2014. The fourth Aim will entail primary qualitative data collection through interviews and observation of nursing homes. Our results will directly inform 1) how consumers should interpret nursing home performance on patient safety measures; 2) how policymakers might refine the measures and identify nursing homes in which performance on the measures may be less reliable; and 3) best practices for meaningful improvement.